Journal of Autism and Childhood Schizophrenia, Vol. 6, No. 1, 1976
Folie d Deux in a Child J o h n F. S i m o n d s I and T h e o d o r e Glenn University of Missouri-Columbia Medical School
Folie gt deux is the transference o f delusional ideas and behaviors from one person to another with whom there has been a close association. Its occurrence in children has been rarely described in the literature, which was reviewed for case reports, diagnostic criteria, and etiological theories. A detailed case history o f a lO-year-old girl who had delusions of special powers and delusions o f persecution as well as hypochondriacal and hysterical symptoms is presented as an example of folie gt deux between child and parent. This girl had developed a symbiotic incestuous relationship with her stepfather, a paranoid schizophrenic patient. Six criteria for making the diagnosis o f folie ~t deux in a child were applied to the case studied. General and specific aspects o f treating this disorder were discussed.
This paper reports a clinical study of folie d deux in a lO-year-old girl who adopted the psychotic thinking and behavior of her stepfather. Particular attention is given to the diagnostic criteria and the treatment of folie d deux.
REVIEW OF THE LITERATURE
Folie d deux is a French term originated by Laseque and Falret (Michaud, 1964) in 1877. It has been defined differently by various authors but the definition of Gralnick (1942) seems to be the most accepted, i.e., "psychiatric entity characterized by the transference of delusional ideas and/or abnormal behavior from one person to one or more others who have been in close association with the primary affected patient." Folie d deux was described most frequently in adults while its occurrence in children was 'Requests for reprints should be sent to Dr. John F. Simonds, Department of Psychiatry, N119 Medical Center, University of Missouri-Columbia, Columbia, Missouri 65201. 61 9 1976 Plenum Publishing C o r p o r a t i o n , 227 West 17th Street, N e w Y o r k , N.Y. 10011. No p a r t of this p u b l i c a t i o n m a y be r e p r o d u c e d , stored in a retrieval system, or t r a n s m i t t e d , in a n y f o r m or b y a n y means, electronic, mechanical, p h o t o c o p y i n g , m i c r o f i l m i n g , recording, or otherwise, w i t h o u t w r i t t e n permission of t h e publisher.
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rarely reported. Laseque and Falret (Michaud, 1964) described folie ~t deux in three girls aged 8 years, 13 years, and 16 years. The girls were reared in different homes, all had low IQs, passive dispositions, and close associations with a delusional person, and all derived secondary gain from their delusion. Laseque and Falret (Michaud, 1964) stated that apprehensive children confined in a limited environment would be most disposed to become echoes of a delusion with which they were associated. Gralnick (1942) reviewed the English literature and found 103 cases of folie fi deux, only two of whom were under age 18. In Waltzer's (1963) study of folie fi deux, the mother and father were diagnosed as paranoid schizophrenic and five children as primary schizophrenic, while five other children had paranoid reactions. Anthony (1970) described some degree of folie ~ deux in two 5-year-old children who had unresolved symbiotic relationships with their psychotic mothers, but he raised the question whether folie fi deux could exist at such a young age. Folie fi deux in children was also reported by Evans and Mersky (1972). DIAGNOSTIC CRITERIA AND ETIOLOGICAL THEORIES Diagnosis of folie fi deux will depend on the criteria accepted. Dewhurst and Todd (1956) gave the following criteria for the diagnosis: intimate association of partners, high degree of similarity in delusional content of the partner's psychosis, and evidence that the partners support and share each others' delusions. Other prerequisites for the development of the disorder according to Coleman and Last (1939) were the advantages that sharing a delusion gave to the person induced and the symbol of authority that the inducer represented for the induced. A condition of social economic poverty contributed to the pathological relationships. Gralnick (1942) summarized some factors he considered important in diagnosing folie fi deux: the length of association with a psychotic person, the dominance of the active partner who imposed delusions on a more submissive partner, the frequency of blood relationships and family relationships, the prepsychotic personality which was often seclusive and suggestible, the common occurrence of the condition among women, and the frequent occurrence of persecutory and religious delusions. Hereditary and environmental elements have been attributed as etiological factors. Gralnick (1942) did not feel that the occurrence of folie ~t deux within families proved the point for hereditary causes since most of the factors needed to produce this condition existed within the family unit. According to Coleman and Last (1939), folie fi deux should be restricted to cases outside of blood-related groups in order to eliminate genetic factors. Other reputed causes included unconscious identifications, imitation, and suggestibility. Gralnick (1942) reported on Brill's theory that the submissive
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partner identified with the aggressor in order to placate him. The same author described the submissive partner becoming anxious about the loss of the dependency relationship should he disagree with his partner. In Anthony's (1970) cases of children with folie ~ deux, a failure of intrapsychic separation against a background of persistent symbiosis was thought to be the cause. He speculated that a biological predetermined deficiency in ego maturation was responsible for the process occurring in some children in a family and not in others. The psychotic mother, according to Anthony, interfered with the psychological development of the child, particularly during the separation individualization phase perpetuating his delusions about the world. In order to preserve the love relationship with his parents, the child compromised his reality testing. CASE HISTORY The following report is a summary of the historical and clinical data on a young girl who was admitted to the children's psychiatric ward at a Mental Health Center.
Presenting Problem The patient (Susan) was a 10-year-old Caucasian girl referred for psychiatric hospitalization by a county court that had temporarily removed the girl from the custody of her natural mother and stepfather. It was the court's impression that the patient's home was not conducive to healthy emotional development and that the stepfather was giving the girl undue emotional responsibility, thereby stifling her self development. Prior to a placement decision, the Division of Welfare wanted a thorough psychiatric evaluation. Four months prior to her admission, Susan's mother and stepfather had obtained a legal separation which gave mother custody of two younger half-siblings and stepfather custody of Susan. Despite the separation, the family remained living in the same house. A blanket was hung across the middle of the house in order to divide the quarters into two separate living arrangements. Mother and her younger children lived on one side of the blanket while father and Susan lived on the other side. Susan and her stepfather also shared the same bed and showed each other mutual physical affection including hand holding, lip kissing, hugging, fondling. Specific sexual intercourse was denied by both parties but breast fondling was admitted by both (Susan's physical development was premature for her age and regular menstrual periods had started at age 10 years). Susan's stepfather did not think there was anything unusual in his plans to marry Susan when she became of age. He felt it was his duty to marry her if a suitable
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husband could not be found. Susan likewise looked forward to the day that they would marry and mother did nothing to change these ideas. Susan's school history had been marked by frequent changes in schools, much scapegoating and ridicule by classmates. Shortly after the parents' legal separation, Susan started the fifth grade in a special education class. When she became ill with the flu, stepfather obtained letters from local doctors excusing Susan from school. He hesitated to send her back to school because some children had been teasing her and threatening to beat her up. After 40 consecutive days of Susan's missing school, the local welfare office decided to investigate the family situation. When a social worker phoned the stepfather, he said that he was afraid Susan's flu would become cancer. A social worker visited the home the next day and found Susan sitting in her stepfather's lap kissing him without concern about the worker's presence. This visit led to further interviews and the decision to make Susan a ward of the court. At the time of admission, the parents stated that Susan had minor problems with nervousness, sadness, vague body pains, and nightmares.
Past Medical History An adequate history could not be obtained from the mother because of her tendency to exaggerate the truth, distort reality, change details, and contradict herself. Medical records from the Medical Center were available which gave some indication of the true situation. The mother's pregnancy was complicated by mild hypertension and spotting during the 8th month. Delivery was uneventful. Susan weighed 7 lb. 14 oz. and had an apgar rating of 10. When Susan was 1 month old, mother reported that the baby was taking her formula poorly. A 2-month follow-up visit revealed a weight of 9 lb. 3 oz. and normal physical examination. By 3 months of age Susan was observed to be smiling, grasping, and rolling over and was described as "very happy." After a lapse of 2 89 years mother returned to the pediatric outpatient clinic complaining that Susan was vomiting after meals and was constipated. Poor oral hygiene was noted but otherwise physical exam Was unremarkable. One month later Susan was admitted to the hospital with a temperature of 103 ~ Right-sided pyelonephritis and a urethral stricture were diagnosed and treated. During this admission the parents described Susan as having "staring" spells and being difficult to discipline. A second hospital admission occurred within a month of the patient's first discharge. She had high fever associated this time with convulsions. An antibiotic course was repeated with recovery from the urinary tract infection. When
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the patient was 7 years old a local doctor requested a Medical Center workup for epilepsy because of parents' report of spells during which Susan would pass out for periods of 5 minutes. An EEG revealed considerable irregular anterior and posterior slow wave activity interrupted by generalized bursts of spikes and spike waves in the posterior temporal regions. The record was regarded as being consistent with a temporal lobe seizure disorder. The family never returned for any treatment, but over the years mother gave the girl Valium tablets, which seemed to help reduce the frequency of the spells.
Past Developmental History This history could not be gleaned from the medical records. According to mother, Susan talked and walked at 12 months and was toilet trained by 21/2 years. She was feeding herself by age 2 and dressing herself by age 5.
Past School History The patient attended eight elementary schools over a 4-year period. School records were obtained to get an objective evaluation of progress. In the first grade Susan was described as unkempt and unaccepted by the other children. Mother would bring Susan to school each morning and spend 10 minutes telling the teacher about Susan's physical problems, particularly the epilepsy. A second-grade teacher reported that Susan seemed emotionally insecure and she thought that this was related to mother crying in front of the teacher and other students about Susan's bad health, During the third grade Susan verbalized about family and self-illnesses. She expressed fears that she would be killed by natural phenomena such as lightning or windstorms. In the fourth grade Susan was chased and teased by her peers. Stepfather began to drive her to and from school in order to avoid these peer interactions. For the short time Susan attended fifth grade special education class, she acted pseudomature and bossy with other peers. Her school work was at fourth-grade level.
Family Background The natural father allegedly ran off with another woman when mother was 5 months pregnant with Susan. Mother (whose credibility certainly was questionable) described the natural father as an alcoholic and a scoundrel and impressed Susan with the same ideas. He also supposedly
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had epilepsy. Court records showed that natural father and mother were divorced when Susan was 3 months of age. Father received custody o f three older children while mother was given custody o f Susan, w h o m the father had never seen. The Mental Health Center could not locate the father. The natural mother, who was 39 years old at the time of Susan's admission, regarded Susan's birth as a " m i s h a p . " Various clinicians described the mother as " a p p r e h e n s i v e , " "educationally limited," " p o o r historian." Mother regarded her health to be p o o r due to heart condition and seizure disorder despite repeated medical examinations which indicated she was in good health. During the psychiatric intake interview mother was loud, talkative, labile in m o o d , illogical, inappropriate in affect. She could not tell a story without obviously contradicting herself. She simulated an apparent heart attack and fell to the floor for a short while. Her " a t t a c k " had hysterical overtones as she quickly was able to recuperate and continue the conversation. Stepfather was 42 years old at the time of Susan's admission. He was married to the mother when Susan was 2V2 years o f age. Having served in the Korean war, he was receiving a 100% disability for " p a r a n o i d psychosis" diagnosed at a VA Hospital. During his interviews with various social workers, he appeared aloof and suspicious. On all occasions he came to the office carrying two suitcases filled with his important papers that he was afraid would be stolen. When questioned prior to the court hearing, he stated he needed Susan to help him around the house and insisted that he would only allow Susan to be taken away over his dead body. No doubt the frequent family moves (averaging one every year) were the result of the father's suspiciousness as well as attempts to get extra m o n e y f r o m welfare sources. Nevertheless the County Welfare department had repeatedly denied requests for A.D.C. because o f stepfather's refusal to supply needed information.
Mental and Physical Status on Admission Susan looked and acted older than 10 years of age. Her mannerisms and gestures were like a grown w o m a n ' s . During the first interview she cried and trembled, stating that she was too nervous to talk and only wanted to be returned to her stepfather. Her anxiety obviously interfered with her ability to understand questions or remember reassurances given to her. She denied having any problems but admitted that she cried often at home. Her fund of information was appropriate for her age. Distractibility was moderate but activity level low. Her m o o d was depressed and she was slow to approach a new situation. Delusional thinking was not obviously present during this
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interview but obsessional thoughts were frequent. Yet thought association seemed logical. When brought back to the ward, she became very timid and clung closely to her therapist. Physical examination revealed a thin, dirty, poorly groomed girl with definite breast development and no evidence of physical disease.
Special Testing During Course of Hospitalization A Wechsler Intelligence Scale for Children (WISC) done shortly after admission showed a full-scale IQ of 77 with a verbal IQ of 90 and a performance IQ of 68. Susan was particularly low in the comprehension and vocabulary subtests. A second WISC done 8 months later revealed a full-scale IQ of 81 with a verbal IQ of 89 and a performance IQ of 76. Wide Range Achievement Test scores for sight reading, spelling, and arithmetic were all at fourth-grade level. An EEG done during the first week of hospitalization was read as " n o r m a l . " A second EEG done 5 months after admission was read as "mildly abnormal and paroxysmal E E G . " In this recording there were scattered slow waves and occasional spike waves posteriorly. During photic stimulation paroxysmal spike discharges were noted.
Initial Hospital Course Shortly after her admission, Susan began to express hypochondriacal ideas much like the mother's complaints. She also believed that she and her stepfather were able to communicate with each other by means of speakers located in her thumb and armpit. At times she would attempt to communicate with him by holding up her thumb and speaking to it like a microphone. She claimed that she could hear father respond. There were many paranoid ideas about people related to her natural father, who she thought would attack her while she was in the hospital. Her affect was labile and the slightest provocation would cause her to cry in very dramatic fashion. It took about 1 month for the patient to feel more comfortable with staff and when her anxiety had lessened her behavior seemed more appropriate. One theme in her early conversations with staff was that she felt like a 15-yearold girl with many responsibilities and wanted to feel like a younger girl. A particular problem for Susan was her consistent tendency to alienate her peers by her loud talk, bossy behavior, overreactions, and poor hygiene. On several occasions Susan was encopretic and would use a sanitary napkin. She referred to the fecal material on the napkin as her menstrual flow. With constant reminders, she began t.o make the differen-
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tiation between diarrhea and menses. Nursing staff took an interest in improving the girl's hygiene by helping her with bathing, washing hair, combing hair, and wearing clean clothes. After 12 days of hospitalization, soiling ceased and the Patient seemed more positive and comfortable. About this time her parents came to visit and told her they would take her home. They had been erroneously informed of the possibility of taking the child home for a visit. Susan became upset when she found out she was not going home. This caused some tearfulness and regression to previous inappropriate behaviors (high-pitched voice, exaggerated body motions, and clinging). The next day the patient argued with a female peer about a watch. Both began to physically fight and during the fight Susan stated that she was about to have a "spell." She proceeded to lie down in bed and her hands and arms began to tremble. Some clonic movements lasting 3 minutes were noted. Her muscles tensed for about 10 minutes but she did not become sleepy. She was able to compose herself, expressed her anger verbally, and went on to play a game with another peer. This was the only behavior which resembled a seizure during the entire hospital period (in view of the positive EEG reported months later). Later the same day of the "spell" Susan ate too much food to the point of choking herself and vomiting. Valium, 2 mg t.i.d., was started on that day because of patient's high anxiety level. The medication was continued for the rest of the hospitalization period. A second visit from her parents was supervised by the therapist. During this visit Susan assumed the role of an older girl and became overly dramatic. The next day Susan again had an argument with a peer almost to the point of having a "spell." With the help of the staff she was able to relax. Two days after the visit she appeared to be preoccupied with a hallucination. She told the staff that she was holding her mother's, father's, sister's, and brother's hands and they were talking to her. When confronted about the reality she began to cry and looked sad. This sadness lasted a day or two. It coincided with the period of time that most of the children on the ward were visiting their families. As soon as the children began to return from their visits Susan became more cheerful and active.
Later Hospital Course Susan participated in both group and individual psychotherapy. She was able to express her feelings and delusions freely. Appropriate reality testing was supported but the inconsistency of her delusions with reality was made clear. As she developed trust in her therapist she gradually gave up her delusions and hallucinations. The ward staff also developed relationships
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with the girl and utilized some behavior modification techniques to reduce the frequency of inappropriate behaviors such as clinging, loud talking, thinking out loud. Susan would seek out female staff members and attempt to model their behavior. Her mood continued to fluctuate but more in relationship to ongoing ward interaction rather than to daydreaming and longing for her stepfather. Her relationship with male peers was slow to improve. She would tease them and run to nurses for protection. Eventually she reacted to their teasing by "mock anger" and finally by ignoring them. Group psychodrama helped her to feel more at ease with the peers. In recreational activities Susan had much difficulty with fine motor skills and was slow to learn new skills. As her peer relationship improved so did her enjoyment of various recreational activities such as swimming, cooking, and trampoline. Susan also was placed in a Girl Scout troop made up of nonpatients in the community. She looked forward to these meetings which more than anything helped to improve her self-confidence. Susan's academic skills improved so that by the time she was discharged (9 months after admission) she was able to function at a low sixthgrade level. It was recommended that she be returned to a low-track regular classroom rather than a special education class.
Contacts with Family and Social Agencies As mentioned previously, the family visited prior to Christmas vacation and this visit caused the patient to become confused. An unscheduled visit occurred right after Christmas but this visit was Supervised by the therapist. The family was told to schedule visits at regular intervals. They made one more visit a month after Susan's admission and did not return again. The local welfare office had put pressure on them to have psychiatric evaluations which they successfully resisted. Three months later mother sent a letter to Susan at the Mental Health Center. She explained that stepfather had taken up with another woman. As time progressed Susan accepted the fact that she would not return to either parent. Attempts to find a foster home that would accept Susan were not successful. Finally it was decided to place Susan in a residential group home.
Formulation The influence of the family pathology on this girl was quite severe due to her high degree of suggestibility. Father, a diagnosed paranoid schizophrenic, encouraged an incestuous relationship with the patient and this
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became overt following the legal separation from his wife. His paranoid ideas about the possibility of physical assault were reinforced in Susan by her peers' ridicule and fighting. Susan felt a close relationship with her stepfather, whom she viewed as protector, lover, and eventual husband. The nature of the delusions concerning the ability to communicate directly with stepfather emphasized the "special" relationship between the two. On the other hand, the girl's relationship with her mother was more distant and one gets the impression that mother was rejecting Susan. Mother's psychiatric disorder was never officially diagnosed. Although she manifested many hypochondriacal and hysterical symptoms, her more recent frantic, illogical behavior might have been an indication of an underlying schizophrenic disorder. Susan's overly dramatic behavior and inordinate preoccupation with bodily processes probably resulted from modeling her mother's behavior. Nevertheless the folie fi deux was primarily between Susan and her stepfather. Although the patient's delusions and hallucinations ceased after the first 6 weeks of hospitalization, she maintained other behaviors which required management and control. Relating to peers was particularly poor because Susan had never learned how to relate appropriately within her own family. Although not initially hostile, she had many irritating mannerisms and habits (such as uncleanliness, bossiness, and inability to inhibit private thoughts) which prompted peer teasing. Once teased Susan would become defensive and strike back either physically or verbally, which resulted in a vicious cycle reaction. This deficit was regarded as a deviation in social development (G.A.P., 1966). Another aspect of the patient's personality which required therapeutic attention was her emotional lability. Sometimes this was manifested by an excessively angry or anxious reaction to a minor environmental situation. Other times she appeared depressed for no apparent reason. When describing physical symptoms she utilized a dramatic flair so often characteristic of patients with hysterical personality disorders. The authors chose to regard this problem as a deviation of affective development (G.A.P., 1966). The patient's transient encopresis and somatic complaints were viewed as physiological concomitants of anxiety, which was high during the initial period of hospitalization. Physical complaints and symptoms were at a minimum when the patient was discharged. There was a suspicion of a temporal lobe seizure disorder, because of the positive EEG findings and the one borderline clinical episode (which could have been an anxiety reaction). It was doubtful that the seizure disorder caused the patient's psychiatric and physical symptoms.
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DISCUSSION
Diagnosis Diagnosis of folie ~tdeux between a child and parent can only be made after thorough evaluation of the child in a setting other than the home environment. A period of psychiatric hospitalization is the best method for performing this evaluation. Any history obtained from the parent may be worthless particularly if the parent is schizophrenic. Records from medical centers and social agencies can be of great value in reconstructing some of the past history. Observation of the child over a period of time in the psychiatric setting will reveal important aspects of mental functioning and behavior that are diagnostic for folie ~t deux. Some of the key diagnostic criteria and specific examples from the case study follow. 1. Remission usually occurs after separation (Michaud, 1964). The patient's delusions and hallucinations disappeared after separation from the parents. She was able to test reality in an age appropriate manner within 6-8 weeks after admission to the hospital. 2. Child models specific delusional content of parent (Michaud, 1964). The patient shared the delusionswith the stepfather and mother. 3.'Child usually communicates the thinking of the deluded parent (Dewhurst, 1956). The patient's thinking and fixed ideas paralleled that of her stepfather and mother. 4. Child's delusions and behavioral symptoms usually show evidence of secondary gain, e.g., to maintain dependency (Coleman & Last, 1939). The patient enjoyed the privileges of playing the role of wife and lover to her stepfather. 5. Child is capable of a close but dependent relationship with the parent (Michaud, 1964). The patient exhibited a warm empathic relationship with the stepfather. 6. Child has higher anxiety level when separated from the parent. The patient manifested marked anxiety when initially separated from the parents but the anxiety subsided as she adjusted to the ward. The patient's delusions, emotions, and behaviors were consistent with the above six criteria for folie fi deux, Her delusions were primarily paranoid and grandiose similar to her stepfather's delusions. She and her stepfather also shared the same hallucination relating to their ability to communicate with one another by means of magical microphones and speakers. Fixed ideas focused on hypochondriacal preoccupations much
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like mother. A tendency to overreact emotionally may have been learned from mother. During the period of initial hospitalization, symptoms of anxiety and depression were related to separation from stepfather and lack of security dealing with strangers. Once the florid symptoms had cleared, an underlying personality disorder or developmental deviation, manifested by excessive dependency, suggestibility, labile affect, and dramatic exaggeration, was evident. A case for diagnosing hysterical personality disorder (G.A.P., 1966) could have been made, but the patient's age and gradual improvement suggested the diagnosis of deviation in social and affective development (G.A.P., 1966). A deviation in cognitive development was probably present prior to admission but gains made during the 9-month period warranted elimination of such a diagnosis at the time of discharge.
Treatment
Falret (Michaud, 1964) stressed the need for separating the person who induces the psychosis (usually the parent) from the person in whom the psychosis is induced (the child). This method of treatment holds true at present. In some situations, separation from the parents has to be accomplished gradually because of the close ties the child has with his parents. With these children, periodic visits with the parents in a structured setting can be spaced out and eventually discontinued. Since separation from the psychotic parent must be permanent (which will involve a custody change), the child will eventually have to be placed in a foster home or residential group home. It is important that the child with folie ~t deux receive initial treatment in a psychiatric hospital setting where treatment can be intensive and multidisciplinary. Individual and milieu therapy provide the main structure for assisting the patient in improving reality testing and distortions in thinking. Group therapy and psychodrama can also be effective techniques for developing social skills with peers and new authority figures. When there are maturational lags, each staff member participates in helping the patient reach higher levels of psychosocial functioning. Not only does the hospital setting provide therapeutic benefits but it also acts as a temporary "home/school"-like environment in which the patient's basic needs are taken care of. The need for medication will depend on specific symptoms. Major tranquilizers are usually not necessary but minor tranquilizers can help to relieve symptoms of anxiety, particularly at the time of initial separation from parents.
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The partner who has primary psychosis also needs evaluation and treatment. Court orders may be required to accomplish such goals. Other dependent children within the family constellation should be evaluated for possible detrimental effects. The particular case under study incorporated the major therapeutic points discussed. The patient was allowed visits from her parents only under staff supervision. Bizarre behavior patterns and social maturation lags were corrected gradually by individual psychotherapy, group psychodrama, and behavior modification techniques. Individual therapy focused on developing a positive relationship with the therapist which ultimately permitted confrontation and correction o f the inappropriate behaviors and delusions. During the course of hospitalization, gains were made in emotional stability and socialization. After 9 months of hospitalization the patient was transferred to a residential group home which had counseling and therapeutic services. The eventual goal was for long-term placement in a stable foster home. It was hoped the deviations in development would improve rather than progress into a personality disorder.
REFERENCES
Anthony, E. J. The influence of maternal psychosis on children--folie fi deux. In E. J. Anthony & T. Benedek (Eds.), Parenthood: Its psychology and psychopathology. Boston: Little Brown & Co., 1970. Coleman, S., & Last, S. A study of folie ~i deux. Journal of Mental Science, 1939, 85, 1212-1223. Dewhurst, K., & Todd, J. The psychosisof association--folie ~ideux. Journal of Nervous and Mental Diseases, 1956, 124, 451-459. Evans, P., & Merskey, H. Shared beliefs of dermal parasitosis: Folie partag6. British Journal of Medical Psychology, 1972, 45, 19-25. Gralnick, A. Folie ~t deux--the psychosis of association. Psychiatric Quarterly, 1942, 16, 230-263. Group for the Advancement of Psychiatry, Committee on Child Psychiatry. Psychopathological Disorders in Childhood: Theoretical Considerations and a Proposed Classification. Volume VI, Report #62, New York, Group for the Advancement of Psy-
chiatry, 1966, pp. 228-240. Michaud, R. (Trans.). La folie d,deux par les Drs. Ch. Laseque et J. Falret. American Journal of Psychiatry, 1964, 4(Suppl. 121), 2-23. Waltzer, H. A psychotic family--folie ~i douze. Journal of Nervous and Mental Diseases, 1963, 137, 67-74.
Folie d Deux in a Child J o h n F. S i m o n d s I and T h e o d o r e Glenn University of Missouri-Columbia Medical School
Folie gt deux is the transference o f delusional ideas and behaviors from one person to another with whom there has been a close association. Its occurrence in children has been rarely described in the literature, which was reviewed for case reports, diagnostic criteria, and etiological theories. A detailed case history o f a lO-year-old girl who had delusions of special powers and delusions o f persecution as well as hypochondriacal and hysterical symptoms is presented as an example of folie gt deux between child and parent. This girl had developed a symbiotic incestuous relationship with her stepfather, a paranoid schizophrenic patient. Six criteria for making the diagnosis o f folie ~t deux in a child were applied to the case studied. General and specific aspects o f treating this disorder were discussed.
This paper reports a clinical study of folie d deux in a lO-year-old girl who adopted the psychotic thinking and behavior of her stepfather. Particular attention is given to the diagnostic criteria and the treatment of folie d deux.
REVIEW OF THE LITERATURE
Folie d deux is a French term originated by Laseque and Falret (Michaud, 1964) in 1877. It has been defined differently by various authors but the definition of Gralnick (1942) seems to be the most accepted, i.e., "psychiatric entity characterized by the transference of delusional ideas and/or abnormal behavior from one person to one or more others who have been in close association with the primary affected patient." Folie d deux was described most frequently in adults while its occurrence in children was 'Requests for reprints should be sent to Dr. John F. Simonds, Department of Psychiatry, N119 Medical Center, University of Missouri-Columbia, Columbia, Missouri 65201. 61 9 1976 Plenum Publishing C o r p o r a t i o n , 227 West 17th Street, N e w Y o r k , N.Y. 10011. No p a r t of this p u b l i c a t i o n m a y be r e p r o d u c e d , stored in a retrieval system, or t r a n s m i t t e d , in a n y f o r m or b y a n y means, electronic, mechanical, p h o t o c o p y i n g , m i c r o f i l m i n g , recording, or otherwise, w i t h o u t w r i t t e n permission of t h e publisher.
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rarely reported. Laseque and Falret (Michaud, 1964) described folie ~t deux in three girls aged 8 years, 13 years, and 16 years. The girls were reared in different homes, all had low IQs, passive dispositions, and close associations with a delusional person, and all derived secondary gain from their delusion. Laseque and Falret (Michaud, 1964) stated that apprehensive children confined in a limited environment would be most disposed to become echoes of a delusion with which they were associated. Gralnick (1942) reviewed the English literature and found 103 cases of folie fi deux, only two of whom were under age 18. In Waltzer's (1963) study of folie fi deux, the mother and father were diagnosed as paranoid schizophrenic and five children as primary schizophrenic, while five other children had paranoid reactions. Anthony (1970) described some degree of folie ~ deux in two 5-year-old children who had unresolved symbiotic relationships with their psychotic mothers, but he raised the question whether folie fi deux could exist at such a young age. Folie fi deux in children was also reported by Evans and Mersky (1972). DIAGNOSTIC CRITERIA AND ETIOLOGICAL THEORIES Diagnosis of folie fi deux will depend on the criteria accepted. Dewhurst and Todd (1956) gave the following criteria for the diagnosis: intimate association of partners, high degree of similarity in delusional content of the partner's psychosis, and evidence that the partners support and share each others' delusions. Other prerequisites for the development of the disorder according to Coleman and Last (1939) were the advantages that sharing a delusion gave to the person induced and the symbol of authority that the inducer represented for the induced. A condition of social economic poverty contributed to the pathological relationships. Gralnick (1942) summarized some factors he considered important in diagnosing folie fi deux: the length of association with a psychotic person, the dominance of the active partner who imposed delusions on a more submissive partner, the frequency of blood relationships and family relationships, the prepsychotic personality which was often seclusive and suggestible, the common occurrence of the condition among women, and the frequent occurrence of persecutory and religious delusions. Hereditary and environmental elements have been attributed as etiological factors. Gralnick (1942) did not feel that the occurrence of folie ~t deux within families proved the point for hereditary causes since most of the factors needed to produce this condition existed within the family unit. According to Coleman and Last (1939), folie fi deux should be restricted to cases outside of blood-related groups in order to eliminate genetic factors. Other reputed causes included unconscious identifications, imitation, and suggestibility. Gralnick (1942) reported on Brill's theory that the submissive
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partner identified with the aggressor in order to placate him. The same author described the submissive partner becoming anxious about the loss of the dependency relationship should he disagree with his partner. In Anthony's (1970) cases of children with folie ~ deux, a failure of intrapsychic separation against a background of persistent symbiosis was thought to be the cause. He speculated that a biological predetermined deficiency in ego maturation was responsible for the process occurring in some children in a family and not in others. The psychotic mother, according to Anthony, interfered with the psychological development of the child, particularly during the separation individualization phase perpetuating his delusions about the world. In order to preserve the love relationship with his parents, the child compromised his reality testing. CASE HISTORY The following report is a summary of the historical and clinical data on a young girl who was admitted to the children's psychiatric ward at a Mental Health Center.
Presenting Problem The patient (Susan) was a 10-year-old Caucasian girl referred for psychiatric hospitalization by a county court that had temporarily removed the girl from the custody of her natural mother and stepfather. It was the court's impression that the patient's home was not conducive to healthy emotional development and that the stepfather was giving the girl undue emotional responsibility, thereby stifling her self development. Prior to a placement decision, the Division of Welfare wanted a thorough psychiatric evaluation. Four months prior to her admission, Susan's mother and stepfather had obtained a legal separation which gave mother custody of two younger half-siblings and stepfather custody of Susan. Despite the separation, the family remained living in the same house. A blanket was hung across the middle of the house in order to divide the quarters into two separate living arrangements. Mother and her younger children lived on one side of the blanket while father and Susan lived on the other side. Susan and her stepfather also shared the same bed and showed each other mutual physical affection including hand holding, lip kissing, hugging, fondling. Specific sexual intercourse was denied by both parties but breast fondling was admitted by both (Susan's physical development was premature for her age and regular menstrual periods had started at age 10 years). Susan's stepfather did not think there was anything unusual in his plans to marry Susan when she became of age. He felt it was his duty to marry her if a suitable
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husband could not be found. Susan likewise looked forward to the day that they would marry and mother did nothing to change these ideas. Susan's school history had been marked by frequent changes in schools, much scapegoating and ridicule by classmates. Shortly after the parents' legal separation, Susan started the fifth grade in a special education class. When she became ill with the flu, stepfather obtained letters from local doctors excusing Susan from school. He hesitated to send her back to school because some children had been teasing her and threatening to beat her up. After 40 consecutive days of Susan's missing school, the local welfare office decided to investigate the family situation. When a social worker phoned the stepfather, he said that he was afraid Susan's flu would become cancer. A social worker visited the home the next day and found Susan sitting in her stepfather's lap kissing him without concern about the worker's presence. This visit led to further interviews and the decision to make Susan a ward of the court. At the time of admission, the parents stated that Susan had minor problems with nervousness, sadness, vague body pains, and nightmares.
Past Medical History An adequate history could not be obtained from the mother because of her tendency to exaggerate the truth, distort reality, change details, and contradict herself. Medical records from the Medical Center were available which gave some indication of the true situation. The mother's pregnancy was complicated by mild hypertension and spotting during the 8th month. Delivery was uneventful. Susan weighed 7 lb. 14 oz. and had an apgar rating of 10. When Susan was 1 month old, mother reported that the baby was taking her formula poorly. A 2-month follow-up visit revealed a weight of 9 lb. 3 oz. and normal physical examination. By 3 months of age Susan was observed to be smiling, grasping, and rolling over and was described as "very happy." After a lapse of 2 89 years mother returned to the pediatric outpatient clinic complaining that Susan was vomiting after meals and was constipated. Poor oral hygiene was noted but otherwise physical exam Was unremarkable. One month later Susan was admitted to the hospital with a temperature of 103 ~ Right-sided pyelonephritis and a urethral stricture were diagnosed and treated. During this admission the parents described Susan as having "staring" spells and being difficult to discipline. A second hospital admission occurred within a month of the patient's first discharge. She had high fever associated this time with convulsions. An antibiotic course was repeated with recovery from the urinary tract infection. When
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the patient was 7 years old a local doctor requested a Medical Center workup for epilepsy because of parents' report of spells during which Susan would pass out for periods of 5 minutes. An EEG revealed considerable irregular anterior and posterior slow wave activity interrupted by generalized bursts of spikes and spike waves in the posterior temporal regions. The record was regarded as being consistent with a temporal lobe seizure disorder. The family never returned for any treatment, but over the years mother gave the girl Valium tablets, which seemed to help reduce the frequency of the spells.
Past Developmental History This history could not be gleaned from the medical records. According to mother, Susan talked and walked at 12 months and was toilet trained by 21/2 years. She was feeding herself by age 2 and dressing herself by age 5.
Past School History The patient attended eight elementary schools over a 4-year period. School records were obtained to get an objective evaluation of progress. In the first grade Susan was described as unkempt and unaccepted by the other children. Mother would bring Susan to school each morning and spend 10 minutes telling the teacher about Susan's physical problems, particularly the epilepsy. A second-grade teacher reported that Susan seemed emotionally insecure and she thought that this was related to mother crying in front of the teacher and other students about Susan's bad health, During the third grade Susan verbalized about family and self-illnesses. She expressed fears that she would be killed by natural phenomena such as lightning or windstorms. In the fourth grade Susan was chased and teased by her peers. Stepfather began to drive her to and from school in order to avoid these peer interactions. For the short time Susan attended fifth grade special education class, she acted pseudomature and bossy with other peers. Her school work was at fourth-grade level.
Family Background The natural father allegedly ran off with another woman when mother was 5 months pregnant with Susan. Mother (whose credibility certainly was questionable) described the natural father as an alcoholic and a scoundrel and impressed Susan with the same ideas. He also supposedly
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had epilepsy. Court records showed that natural father and mother were divorced when Susan was 3 months of age. Father received custody o f three older children while mother was given custody o f Susan, w h o m the father had never seen. The Mental Health Center could not locate the father. The natural mother, who was 39 years old at the time of Susan's admission, regarded Susan's birth as a " m i s h a p . " Various clinicians described the mother as " a p p r e h e n s i v e , " "educationally limited," " p o o r historian." Mother regarded her health to be p o o r due to heart condition and seizure disorder despite repeated medical examinations which indicated she was in good health. During the psychiatric intake interview mother was loud, talkative, labile in m o o d , illogical, inappropriate in affect. She could not tell a story without obviously contradicting herself. She simulated an apparent heart attack and fell to the floor for a short while. Her " a t t a c k " had hysterical overtones as she quickly was able to recuperate and continue the conversation. Stepfather was 42 years old at the time of Susan's admission. He was married to the mother when Susan was 2V2 years o f age. Having served in the Korean war, he was receiving a 100% disability for " p a r a n o i d psychosis" diagnosed at a VA Hospital. During his interviews with various social workers, he appeared aloof and suspicious. On all occasions he came to the office carrying two suitcases filled with his important papers that he was afraid would be stolen. When questioned prior to the court hearing, he stated he needed Susan to help him around the house and insisted that he would only allow Susan to be taken away over his dead body. No doubt the frequent family moves (averaging one every year) were the result of the father's suspiciousness as well as attempts to get extra m o n e y f r o m welfare sources. Nevertheless the County Welfare department had repeatedly denied requests for A.D.C. because o f stepfather's refusal to supply needed information.
Mental and Physical Status on Admission Susan looked and acted older than 10 years of age. Her mannerisms and gestures were like a grown w o m a n ' s . During the first interview she cried and trembled, stating that she was too nervous to talk and only wanted to be returned to her stepfather. Her anxiety obviously interfered with her ability to understand questions or remember reassurances given to her. She denied having any problems but admitted that she cried often at home. Her fund of information was appropriate for her age. Distractibility was moderate but activity level low. Her m o o d was depressed and she was slow to approach a new situation. Delusional thinking was not obviously present during this
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interview but obsessional thoughts were frequent. Yet thought association seemed logical. When brought back to the ward, she became very timid and clung closely to her therapist. Physical examination revealed a thin, dirty, poorly groomed girl with definite breast development and no evidence of physical disease.
Special Testing During Course of Hospitalization A Wechsler Intelligence Scale for Children (WISC) done shortly after admission showed a full-scale IQ of 77 with a verbal IQ of 90 and a performance IQ of 68. Susan was particularly low in the comprehension and vocabulary subtests. A second WISC done 8 months later revealed a full-scale IQ of 81 with a verbal IQ of 89 and a performance IQ of 76. Wide Range Achievement Test scores for sight reading, spelling, and arithmetic were all at fourth-grade level. An EEG done during the first week of hospitalization was read as " n o r m a l . " A second EEG done 5 months after admission was read as "mildly abnormal and paroxysmal E E G . " In this recording there were scattered slow waves and occasional spike waves posteriorly. During photic stimulation paroxysmal spike discharges were noted.
Initial Hospital Course Shortly after her admission, Susan began to express hypochondriacal ideas much like the mother's complaints. She also believed that she and her stepfather were able to communicate with each other by means of speakers located in her thumb and armpit. At times she would attempt to communicate with him by holding up her thumb and speaking to it like a microphone. She claimed that she could hear father respond. There were many paranoid ideas about people related to her natural father, who she thought would attack her while she was in the hospital. Her affect was labile and the slightest provocation would cause her to cry in very dramatic fashion. It took about 1 month for the patient to feel more comfortable with staff and when her anxiety had lessened her behavior seemed more appropriate. One theme in her early conversations with staff was that she felt like a 15-yearold girl with many responsibilities and wanted to feel like a younger girl. A particular problem for Susan was her consistent tendency to alienate her peers by her loud talk, bossy behavior, overreactions, and poor hygiene. On several occasions Susan was encopretic and would use a sanitary napkin. She referred to the fecal material on the napkin as her menstrual flow. With constant reminders, she began t.o make the differen-
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tiation between diarrhea and menses. Nursing staff took an interest in improving the girl's hygiene by helping her with bathing, washing hair, combing hair, and wearing clean clothes. After 12 days of hospitalization, soiling ceased and the Patient seemed more positive and comfortable. About this time her parents came to visit and told her they would take her home. They had been erroneously informed of the possibility of taking the child home for a visit. Susan became upset when she found out she was not going home. This caused some tearfulness and regression to previous inappropriate behaviors (high-pitched voice, exaggerated body motions, and clinging). The next day the patient argued with a female peer about a watch. Both began to physically fight and during the fight Susan stated that she was about to have a "spell." She proceeded to lie down in bed and her hands and arms began to tremble. Some clonic movements lasting 3 minutes were noted. Her muscles tensed for about 10 minutes but she did not become sleepy. She was able to compose herself, expressed her anger verbally, and went on to play a game with another peer. This was the only behavior which resembled a seizure during the entire hospital period (in view of the positive EEG reported months later). Later the same day of the "spell" Susan ate too much food to the point of choking herself and vomiting. Valium, 2 mg t.i.d., was started on that day because of patient's high anxiety level. The medication was continued for the rest of the hospitalization period. A second visit from her parents was supervised by the therapist. During this visit Susan assumed the role of an older girl and became overly dramatic. The next day Susan again had an argument with a peer almost to the point of having a "spell." With the help of the staff she was able to relax. Two days after the visit she appeared to be preoccupied with a hallucination. She told the staff that she was holding her mother's, father's, sister's, and brother's hands and they were talking to her. When confronted about the reality she began to cry and looked sad. This sadness lasted a day or two. It coincided with the period of time that most of the children on the ward were visiting their families. As soon as the children began to return from their visits Susan became more cheerful and active.
Later Hospital Course Susan participated in both group and individual psychotherapy. She was able to express her feelings and delusions freely. Appropriate reality testing was supported but the inconsistency of her delusions with reality was made clear. As she developed trust in her therapist she gradually gave up her delusions and hallucinations. The ward staff also developed relationships
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with the girl and utilized some behavior modification techniques to reduce the frequency of inappropriate behaviors such as clinging, loud talking, thinking out loud. Susan would seek out female staff members and attempt to model their behavior. Her mood continued to fluctuate but more in relationship to ongoing ward interaction rather than to daydreaming and longing for her stepfather. Her relationship with male peers was slow to improve. She would tease them and run to nurses for protection. Eventually she reacted to their teasing by "mock anger" and finally by ignoring them. Group psychodrama helped her to feel more at ease with the peers. In recreational activities Susan had much difficulty with fine motor skills and was slow to learn new skills. As her peer relationship improved so did her enjoyment of various recreational activities such as swimming, cooking, and trampoline. Susan also was placed in a Girl Scout troop made up of nonpatients in the community. She looked forward to these meetings which more than anything helped to improve her self-confidence. Susan's academic skills improved so that by the time she was discharged (9 months after admission) she was able to function at a low sixthgrade level. It was recommended that she be returned to a low-track regular classroom rather than a special education class.
Contacts with Family and Social Agencies As mentioned previously, the family visited prior to Christmas vacation and this visit caused the patient to become confused. An unscheduled visit occurred right after Christmas but this visit was Supervised by the therapist. The family was told to schedule visits at regular intervals. They made one more visit a month after Susan's admission and did not return again. The local welfare office had put pressure on them to have psychiatric evaluations which they successfully resisted. Three months later mother sent a letter to Susan at the Mental Health Center. She explained that stepfather had taken up with another woman. As time progressed Susan accepted the fact that she would not return to either parent. Attempts to find a foster home that would accept Susan were not successful. Finally it was decided to place Susan in a residential group home.
Formulation The influence of the family pathology on this girl was quite severe due to her high degree of suggestibility. Father, a diagnosed paranoid schizophrenic, encouraged an incestuous relationship with the patient and this
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became overt following the legal separation from his wife. His paranoid ideas about the possibility of physical assault were reinforced in Susan by her peers' ridicule and fighting. Susan felt a close relationship with her stepfather, whom she viewed as protector, lover, and eventual husband. The nature of the delusions concerning the ability to communicate directly with stepfather emphasized the "special" relationship between the two. On the other hand, the girl's relationship with her mother was more distant and one gets the impression that mother was rejecting Susan. Mother's psychiatric disorder was never officially diagnosed. Although she manifested many hypochondriacal and hysterical symptoms, her more recent frantic, illogical behavior might have been an indication of an underlying schizophrenic disorder. Susan's overly dramatic behavior and inordinate preoccupation with bodily processes probably resulted from modeling her mother's behavior. Nevertheless the folie fi deux was primarily between Susan and her stepfather. Although the patient's delusions and hallucinations ceased after the first 6 weeks of hospitalization, she maintained other behaviors which required management and control. Relating to peers was particularly poor because Susan had never learned how to relate appropriately within her own family. Although not initially hostile, she had many irritating mannerisms and habits (such as uncleanliness, bossiness, and inability to inhibit private thoughts) which prompted peer teasing. Once teased Susan would become defensive and strike back either physically or verbally, which resulted in a vicious cycle reaction. This deficit was regarded as a deviation in social development (G.A.P., 1966). Another aspect of the patient's personality which required therapeutic attention was her emotional lability. Sometimes this was manifested by an excessively angry or anxious reaction to a minor environmental situation. Other times she appeared depressed for no apparent reason. When describing physical symptoms she utilized a dramatic flair so often characteristic of patients with hysterical personality disorders. The authors chose to regard this problem as a deviation of affective development (G.A.P., 1966). The patient's transient encopresis and somatic complaints were viewed as physiological concomitants of anxiety, which was high during the initial period of hospitalization. Physical complaints and symptoms were at a minimum when the patient was discharged. There was a suspicion of a temporal lobe seizure disorder, because of the positive EEG findings and the one borderline clinical episode (which could have been an anxiety reaction). It was doubtful that the seizure disorder caused the patient's psychiatric and physical symptoms.
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DISCUSSION
Diagnosis Diagnosis of folie ~tdeux between a child and parent can only be made after thorough evaluation of the child in a setting other than the home environment. A period of psychiatric hospitalization is the best method for performing this evaluation. Any history obtained from the parent may be worthless particularly if the parent is schizophrenic. Records from medical centers and social agencies can be of great value in reconstructing some of the past history. Observation of the child over a period of time in the psychiatric setting will reveal important aspects of mental functioning and behavior that are diagnostic for folie ~t deux. Some of the key diagnostic criteria and specific examples from the case study follow. 1. Remission usually occurs after separation (Michaud, 1964). The patient's delusions and hallucinations disappeared after separation from the parents. She was able to test reality in an age appropriate manner within 6-8 weeks after admission to the hospital. 2. Child models specific delusional content of parent (Michaud, 1964). The patient shared the delusionswith the stepfather and mother. 3.'Child usually communicates the thinking of the deluded parent (Dewhurst, 1956). The patient's thinking and fixed ideas paralleled that of her stepfather and mother. 4. Child's delusions and behavioral symptoms usually show evidence of secondary gain, e.g., to maintain dependency (Coleman & Last, 1939). The patient enjoyed the privileges of playing the role of wife and lover to her stepfather. 5. Child is capable of a close but dependent relationship with the parent (Michaud, 1964). The patient exhibited a warm empathic relationship with the stepfather. 6. Child has higher anxiety level when separated from the parent. The patient manifested marked anxiety when initially separated from the parents but the anxiety subsided as she adjusted to the ward. The patient's delusions, emotions, and behaviors were consistent with the above six criteria for folie fi deux, Her delusions were primarily paranoid and grandiose similar to her stepfather's delusions. She and her stepfather also shared the same hallucination relating to their ability to communicate with one another by means of magical microphones and speakers. Fixed ideas focused on hypochondriacal preoccupations much
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like mother. A tendency to overreact emotionally may have been learned from mother. During the period of initial hospitalization, symptoms of anxiety and depression were related to separation from stepfather and lack of security dealing with strangers. Once the florid symptoms had cleared, an underlying personality disorder or developmental deviation, manifested by excessive dependency, suggestibility, labile affect, and dramatic exaggeration, was evident. A case for diagnosing hysterical personality disorder (G.A.P., 1966) could have been made, but the patient's age and gradual improvement suggested the diagnosis of deviation in social and affective development (G.A.P., 1966). A deviation in cognitive development was probably present prior to admission but gains made during the 9-month period warranted elimination of such a diagnosis at the time of discharge.
Treatment
Falret (Michaud, 1964) stressed the need for separating the person who induces the psychosis (usually the parent) from the person in whom the psychosis is induced (the child). This method of treatment holds true at present. In some situations, separation from the parents has to be accomplished gradually because of the close ties the child has with his parents. With these children, periodic visits with the parents in a structured setting can be spaced out and eventually discontinued. Since separation from the psychotic parent must be permanent (which will involve a custody change), the child will eventually have to be placed in a foster home or residential group home. It is important that the child with folie ~t deux receive initial treatment in a psychiatric hospital setting where treatment can be intensive and multidisciplinary. Individual and milieu therapy provide the main structure for assisting the patient in improving reality testing and distortions in thinking. Group therapy and psychodrama can also be effective techniques for developing social skills with peers and new authority figures. When there are maturational lags, each staff member participates in helping the patient reach higher levels of psychosocial functioning. Not only does the hospital setting provide therapeutic benefits but it also acts as a temporary "home/school"-like environment in which the patient's basic needs are taken care of. The need for medication will depend on specific symptoms. Major tranquilizers are usually not necessary but minor tranquilizers can help to relieve symptoms of anxiety, particularly at the time of initial separation from parents.
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The partner who has primary psychosis also needs evaluation and treatment. Court orders may be required to accomplish such goals. Other dependent children within the family constellation should be evaluated for possible detrimental effects. The particular case under study incorporated the major therapeutic points discussed. The patient was allowed visits from her parents only under staff supervision. Bizarre behavior patterns and social maturation lags were corrected gradually by individual psychotherapy, group psychodrama, and behavior modification techniques. Individual therapy focused on developing a positive relationship with the therapist which ultimately permitted confrontation and correction o f the inappropriate behaviors and delusions. During the course of hospitalization, gains were made in emotional stability and socialization. After 9 months of hospitalization the patient was transferred to a residential group home which had counseling and therapeutic services. The eventual goal was for long-term placement in a stable foster home. It was hoped the deviations in development would improve rather than progress into a personality disorder.
REFERENCES
Anthony, E. J. The influence of maternal psychosis on children--folie fi deux. In E. J. Anthony & T. Benedek (Eds.), Parenthood: Its psychology and psychopathology. Boston: Little Brown & Co., 1970. Coleman, S., & Last, S. A study of folie ~i deux. Journal of Mental Science, 1939, 85, 1212-1223. Dewhurst, K., & Todd, J. The psychosisof association--folie ~ideux. Journal of Nervous and Mental Diseases, 1956, 124, 451-459. Evans, P., & Merskey, H. Shared beliefs of dermal parasitosis: Folie partag6. British Journal of Medical Psychology, 1972, 45, 19-25. Gralnick, A. Folie ~t deux--the psychosis of association. Psychiatric Quarterly, 1942, 16, 230-263. Group for the Advancement of Psychiatry, Committee on Child Psychiatry. Psychopathological Disorders in Childhood: Theoretical Considerations and a Proposed Classification. Volume VI, Report #62, New York, Group for the Advancement of Psy-
chiatry, 1966, pp. 228-240. Michaud, R. (Trans.). La folie d,deux par les Drs. Ch. Laseque et J. Falret. American Journal of Psychiatry, 1964, 4(Suppl. 121), 2-23. Waltzer, H. A psychotic family--folie ~i douze. Journal of Nervous and Mental Diseases, 1963, 137, 67-74.
